Should you always be able to practice what you preach? Being in a profession within the healthcare system many people have asked me am I capable of doing everything that I normally ask of my clients, be in strength, mobility or balance related. The simple answer is no, I cannot do everything that I often expect and seek from others. This can present some what like an irony that I would not consider myself to me injured or currently harboring a condition but I cannot do some of the things I ask from those that do. The honest answer is that regardless of what you may try and teach someone and expect them to be able to replicate each person has different body structures and capabilities. Each person has also developed differently including their health history regarding the injuries they have sustained and they way in which thy have recovered from these injuries. So very rarely do you find someone who is perfectly functional by the standards we test people. To the extent that when I access someone who is perfectly functional I’m almost shocked.
I have gone through my fair share of injuries so If I was to be tested for things such as ankle or shoulder stability someone may think that I may currently be carrying an injury but as of right this second I’m good. We are not always capable of doing the tests and assessments that we use to grade individuals musculoskeletal health. At times we can hold the testing methods we use a little to strongly. As those who are testing these people and trying to push them forward it can at times create goals that can be excessively difficult for people to cross. People are sometimes not capable of reaching what is perceived to be perfect functionality but most are still capable of doing the sports or events that they wish to undertake. There are always ways around certain functional shortcomings. This may mean doing things in an unconventional manner or simply by breaking activities down to their base elements.
At the same time most people involved in health and sports related activities need to be able to do the basic requirements of that activity. Be it simple skills or some of the functional movements that are heavily demanded in the sport, it is essential purely because to understand the sport and what is demanded of those involved, the best way to help them and make their plan applicable to them and their sports is to be able to understand the sport at a basic level and recreate it. Not to be able to understand every fine nuance of a game but to see the way an individual moves and the way this interacts with surrounding players or athletes can at times be one of the most valuable assets you can have. To understand how an athlete should move in their position and how they normally move themselves can lead you down a path where you realise that they may be carrying an injury or weakness. Seeing a player act differently or out of character can lead you to help them to overcome what may be effecting their game. Behind games, and this is especially true for athletes, lies the core of an individual. So if you cant put yourself in their shoes you may miss the signs behind certain problems. You are not a mind reader although many expect us to be. But at the same time make sure you can practice what you preach, to a certain degree, even to understand where your clients and athletes are coming from to better help them and to allow yourself to keep up with the hectic demands of a physical and demanding job.
In my profession I help a lot of people to return from injury, be it chronic or acute, it is my job and my drive to get people back to a position where they can return to a healthy and functional condition, if not get them to a position where they can become even better than they were before injury. I have done this and regularly guide, and at times convince people, to give their best efforts towards this end goal. Although I get great satisfaction from helping people to return from injury I have always found it difficult to produce the same level of intensity in my own rehab and return from injury. I myself have until recently been injured or returning from injury for a little over 5 years. My life definitely dramatically changed after injury and lead to a domino effect of injury, rehab followed by complications, rehab and what seemed like an up hill struggle to return to a point where I could confidently under take the activities I wanted to without having to worry about what may happen.
My uphill struggle began in my first few weeks of college when I ended up getting a Talor dome fracture to my ankle damaging all of my lateral ligaments in the process. It occurred in the final three minutes of a rugby game in which a fluke fall and tackle interacted to cause the injury. I had began my Athletic Rehabilitation course and so I had my ankle accessed and was quickly sent to a clinic to get the ankle scanned. Before I made my way to the hospital I went to where I was staying and ended up hitting my ankle off the steps of the stairs attempting to climb them and due to the shock and pain I ended up fainting and collapsing at the top of the stairs. I went to the hospital the following morning but was told there was no fracture, merely ligament damage so I was to just rest it and it would be fine. I proceeded to attend 3 days of college before one of my lecturers told me I was being foolish and was to go home and rest as I was so tired walking around with crutches from one lecture to another that I kept falling asleep in classes.
I attended the hospital several times over the following 2 months where the assessment of my injury changed per visit. This aggravated me and I couldn’t understand where I stood with it all so I decided I would rest it and do my bit of rehab I had gotten and make a return to rugby and normal life. I spent a year getting back to walking normally but something wasn’t right. My entire leg appeared to have rotated inwards and I was unable to walk more than 5 minutes before pain would make me stop and take a break before I could walk again. In this time I had thrown my efforts into gym work and it was a saving grace but there was a very large gap left by rugby and not because I was a skilled athlete but merely because I had played rugby every year up to this point since I was 6 years old. It was a constant in my life at that point and it was where I had made most of my friends through out as well.
I had decided after a year of this that I had finally had enough and went about getting an appointment with a consultant as rehab, no matter how much effort or dedication I applied to it, was no longer helping and I had changed a number of aspects in my life that I would never have even had to give a second thought about previously. Upon meeting the specialist and getting an MRI I had found out that i had a piece of cartilage that had calcified in the center of the joint as well as a piece of cartilage on the medial edge of the joint that had torn away from the joint line. This was not the worst case scenario and key hole surgery was possible so I agreed to a date there and then. I decided to get it done the summer before third year as that was when my placement began and I needed to be able to walk and stand and just move to do it. So i gave up Summer to be alright for the coming college year. I entered the day of surgery and wasn’t nervous. I had learned a lot already and knew what they were going to do to my ankle. I was more impatient if anything. They rolled me in to the anesthetists and nearly as soon as I remember being wheeled in I was awake back in my corner of the ward post surgery. I began to come to and the pain hit me like a truck at first. Each pulse seemed like agony and it felt like someone raised the temperature in that one ward by about 20 degrees.
My doctor soon came over to me and told me the physiotherapist would be with me soon to talk everything out. I honestly only picked up every second word because I had finally noticed the massive full length leg boot I had on. He only stayed a short time but he told me it was a success and that he would see me in a week. I waited around for my dad to show up and take me away so I fiddled around on my phone and let everyone I knew know that that I was out and in a lot of pain. The physiotherapist came to show me how to use my crutches, little did she know I was a seasoned expert at them by now. I feel bad for her now looking back as I was standing and straight over to the bathroom before she even got a chance to fully explain it all. I got my tea and toast and eventually my dad arrived. I was still feeling the effects of the pain and drugs so I didn’t even realise how long I had been under for. I arrived home and went to sleep or at least what sleep was with a massive boot on your leg. My first real day began with me slipping down the stairs as I fell trying to get myself to the bathroom and me having to go to Shannon Doc to get stronger pain medication. Three days later my letter describing the surgery arrived and I read exactly what had occurred. My key hole surgery of one hour had turned into a four and a half hour surgery involving the removal of cartilage, removal of a bone growth, reconstruction of my Deltoid ligament complex and removal of excess tissue from around my Achilles. I had yet to open my boot so after reading my letter I did to notice I had more than just two dots as scars of my surgery.
My plan slightly backfired so I did rehab and work throughout the Summer but it took 6 months before I was back walking again. Thankfully at this point I was deep into the rehab phase and almost back to normal. Normal sadly did not mean I was able to return to the gym or rugby yet with another 6 months of mobility, balance and strength work needed before I was at the point where I could comfortably enjoy a gym session or a long walk again. I finished out my last year of college and just recently started to play rugby again. My body still remembers what to do but its a few steps behind what my brain demands from it. I still have difficulty and am sore to some degree but in comparison to where I was, where walking was near impossible for long periods, its like a whole different world. Looking back as a qualified health practitioner now I can barely believe the way I went about things. I refused to take proper care of myself and even held onto the belief that because of what my course was, that I knew how to sort my problems. Present me can scarcely believe my naivety but it also gave me a perspective on what pain and injury was and how people view their injuries and themselves while injured. Sort of like a person who has never been to a certain location can never truely describe it, long term and chronic injury is very much a unique journey for everyone. Im glad that my road to recovery has come to its end but now the road to performance has only started.
Pain is always a very difficult topic to discuss. So many people describe pain in different ways and pain itself and the idea of what it truly is, how its perceived and what we should do when we experience, especially in terms of injuries or activity, seems to change on a regular basis. For a long time therapists use to chase the pain finding the symptoms of pain, leading to initial short term improvements but never caused the pain to fully leave or the true cause to be chased down and dealt with. We as humans became heavily dependent on getting rid of pain so we could function long enough to compete or just get through the day. this lead to many people suffering in the long term, with tissues being damaged and movement patterns leading to injuries merely being ignored instead of changed. The international association for the study of pain describe pain as “An unpleasant sensory and emotional experience associated or as a result of actual or potential tissue damage”.
In certain sports they have become dependent on the idea of deal with the pain to allow an individual to compete for a long enough period and then to essentially come off injured. American Football is the worst culprit for this and still continues to chase the symptoms instead of the cause. Sadly leading to the abuse of NSAIDS, painkillers normally injected into an affected area but the overuse of which can cause tissue degeneration. Other sports have already moved away from such methods but often we find ourselves stuck in a situation where we have an athlete asking to play and willing to push through an injury, coaches balancing their want for player safety and need to produce results and therapists stuck between the want of their patient and the knowledge of what is truly occurring to them and what will occur with further stress.
People often want a quick solution and don’t want the hassle of consistent or prolonged rehab or activity when a quick solution of masking the pain will allow them to do the same. America alone spends $323 billion dollar in 2015 on pain medication with it likely to increase to $450 billion by 2021. Obviously this includes individuals taking pain medication for conditions that cannot be cured through rehabilitation and activity but a huge sum of this money is towards people suffering chronic but curable pain as well acute pain due to musculoskeletal injuries or tension. Looking then to the entire world the money spent on short term relief of pain is astronomical in comparison to the price of what rehabilitation or increased levels of activity cost in the long run.
The issue with always masking or reducing pain is that pain is not always a bad thing. Pain normally allows for us to find the cause or the issue or the reason behind injuries. It also allows us to prevent ourselves from returning to a position where our tissues cannot, at that time, deal with the loading asked of them. Pain is a way for your body to protect itself by trying to force us out of positions or activities that is causing damage or this sensation to be produced. Pain not only causes physical changes but mental as both are interlinked to a level where we often cannot control it. Pain will lead to physical change which will lead to mental changes in the form of a change in movement patterns and the reaction to fear. This is often an unconscious factor but often leads to prolonged changes in the way we function. We can also become over saturated with pain meaning we can become hypersensitive to it or almost numb to its presence, both as bad as the other in functional terms.
Pain can illicit a response from several systems including the motor, endocrine, sympathetic nervous and immune system. Pain also does not always mean tissue damage in the sense of an injury. For muscle and tissue to correctly develop it has to be broken down and built up, with the correct loading for more avascular tissues. Pain is also exceedingly selective with pain producing a different response or level of pain depending on its cause or placement of injury depending on the activities of each person e.g. knee pain in an Olympic weight lifter vs a musician. Our body has specific healing phases with each tissue type having a different time-frame of healing. Masking the pain or introducing exterior stimuli to reduce pain before these stages are complete to an excessive level can cause issues where a premature return to activity occurs several times causing chronic problems.
Our biggest issue stems from a mixture of refusing to spend the time needed on correct rehab to produce long standing results and our lives revolving around excessively sedentary lifestyles. We only need to be active in the correct manor for short periods each day but we find it difficult to entertain the idea of it. Time seems to be the real killer with us normally not having the patience or willingness to give time over to what seems hard to make things easy in the long run, instead doing what is easy and maintaining what is wrong for the long run.
Recently I attended the Coaching Masterclass event held in Dublin City University. Coaching itself is not something I wish to do as a profession but the premise behind good quality coaching can help with dealing with patients and receiving the best quality effort from them.
Often coaches, therapists and others, who would be perceived to be in a position of authority and care, can fail to communicate to the people that come to them. As professionals in our fields we often talk to athletes or patients and tell them what to do. Not always necessarily listening to their own views and difficulties on the matter. We often lose ourselves in the idea that we know best and that doggedly persevering through any form of set back or failure without making changes will work.
This is of course is a selfish ideal that we can all fall in to. Thinking we know best and that if others just listen to you and do as you say, well then of course they will improve. Sadly this is not true for most. We have seen now for years that not every form of learning will suit each person, “One size fits all” does not always apply. Within the event better ways to communicate and understand athletes as well as people in general were presented by coaches, sports scientists, sports psychologists and experts of human behavior.
We sometimes act like most people will improve at a steady and homogeneous rate. This is often a trap that health care providers fall in to with set backs and slow progress stumping many of us purely because “Well why wouldn’t it be working”. Its the exact same way in which we look at performance. We often look at the potential in individuals and we can see where they could end up, but just as many of the people speaking at the event made reference to, you can have the greatest car in the world but it will only drive as well as the person behind the wheel. Simple example but it holds true to anyone trying to come back from injury or improve their performance. Your body has all the capability in the world, but the effort you put into it and the decisions you make are what determines the outcome.
We normally see this in private when a person can perform to a high standard with ques and a presence to guide them step by step. Adversely we see them falter and become unsure in an open environment with unknowns and the fear of return to play. As such we need to be able to communicate with our athletes/patients in a manner that allows them to grow as an individual with the necessary skills to not only return to general activity but excel in it. These individuals must not be afraid of stumbles and failures as they will be what allows them to grow.
We all want those we aid to grow more and more but each individual is different and cannot always fall under broad methods of training or learning. We cannot merely tell them what to do at every given period. We need to instill in them to ability to return from injury and know the way to prevent re-injury. This can be difficult as most people are in a rush and want to be told what they need to do, step by step. Challenging them while aiding their physical return to play may be what is truly necessary in the long run for player health and longevity within a sport. Knowing the ques for the best result and describe where an individual truly both mentally and physically are also necessary.
Performance as well as the rate a person progresses in their rehab is seen as 90% preparation. If we do not adequately challenge people with factors relatable to their sports or general activities and merely cater to their ability to complete abitrary tasks away from a true to life scenario then we are merely setting them up for a fall. Rehab must become something where the patient, those involved with them and ourselves all share a common goal in mind that we all strive to achieve, a “shared mental model”. This system where we strengthen not just a person physically but also mentally is where we make people return and become even better than they were as staying the same in their position means they aren’t getting better. This responsibility given to the individual will hopefully make them try harder and make them more open to try methods on their return to full health and continuous improvement in their performance, be it on the field of in every day life.